Nokea
A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action?
- A. Encourage frequent mouth care
- B. Cleanse the tongue and mouth with glycerin swabs
- C. Obtain a soft diet for the client
- D. Administer a topical analgesic per PRN protocol.
Correct Answer: D
Rationale: Administering a topical analgesic provides immediate pain relief, allowing the client to tolerate mouth care and other interventions.
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The following are true statements:
- A. Tissue plasminogen activator is derived from endothelium
- B. Heparin acts through antithrombin III
- C. Protein C deficiency is autosomal recessive transmitted
- D. Protein C is vitamin K dependent
Correct Answer: B
Rationale: Heparin acts through antithrombin III: Heparin enhances the activity of antithrombin III, which inhibits thrombin and other clotting factors, helping prevent clot formation.
Features of severe folate deficiency include:
- A. Steatorrhoea
- B. Glossitis
- C. Leucoerythroblastic picture
- D. Increased total iron binding capacity
Correct Answer: B
Rationale: Glossitis, or inflammation of the tongue, is a common feature of folate deficiency due to its role in cell division and growth.
Inability to do which of the following in a 20-month child is cause for concern?
- A. Speak in clear two to three word phrases
- B. Walk unaided
- C. Kick a ball
- D. Build a tower of 8 blocks
Correct Answer: B
Rationale: Inability to walk unaided by 20 months is a red flag for developmental delay. Other skills are more variable and less concerning if delayed.
What are THREE long-term complications in repaired Tetralogy of Fallot?
- A. Arrhythmia
- B. Pulmonary valve insufficiency
- C. Sudden Death
- D. Recurrent PS
Correct Answer: D
Rationale: Patients with repaired Tetralogy of Fallot are at risk of long-term complications such as recurrent pulmonary stenosis, arrhythmias, and valve insufficiencies.
Which is best described as the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures?
- A. Pulmonary congestion
- B. Congenital heart defect
- C. Heart failure
- D. Systemic venous congestion
Correct Answer: C
Rationale: The definition of heart failure is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the body’s metabolic demands. Pulmonary congestion is an excessive accumulation of fluid in the lungs. Congenital heart defect is a malformation of the heart present at birth. Systemic venous congestion is an excessive accumulation of fluid in the systemic vasculature.